The Multidisciplinary Approach to Managing People With Comorbidities in Type 2 Diabetes
In this video roundtable discussion, Carol Wysham, MD, interviews Eugene E. Wright, Jr., MD, and Hope Warshaw, MMSc, RD, CDCES, BC-ADM, about the multidisciplinary approach to managing people with comorbidies in type 2 diabetes, including cardiovascular disease, chronic kidney disease, congestive heart failure, and metabolic dysfunction-associated fatty liver disease, and the importance of lifestyle changes and diabetes education.
Additional Resources:
ElSayed NA, Aleppo G, Aroda VR, et al.; on behalf of the American Diabetes Association. Introduction and Methodology: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S1-S4. doi:10.2337/dc23-Sint
Hope Warshaw. Accessed October 25, 2023. https://www.hopewarshaw.com/
For more diabetes content, visit the disease state hub.
TRANSCRIPTION:
Dr Carol Wysham:
Welcome to Consultant 360. Today we'll be discussing the multidisciplinary approach to the management of comorbidities and type 2 diabetes, including cardiovascular disease, chronic kidney disease, congestive heart failure, as well as fatty liver disease, the new terminology being metabolic-associated fatty liver disease, better known as MAFLD.
I am Dr Carol Wysham. I'm an endocrinologist at MultiCare Rockwood Clinic in Spokane, Washington. I'm joined by my two esteemed colleagues, Dr Eugene Wright and Ms Hope Warshaw. I'd like you to introduce yourselves and define your role in managing patients and their comorbidities and diabetes. Gene?
Dr Eugene E. Wright:
My name is Gene E. Wright. I'm an internist. I currently serve as the medical director for performance improvement at the South Piedmont Area Health Education Center. As a primary care clinician, we see patients with diabetes and many of the associated comorbidities. So in many respects, we find ourselves being the multi-specialists in the care of these patients.
Dr Carol Wysham:
Thank you. And Hope?
Hope Warshaw:
I am, by background, a registered dietician, and I am a certified diabetes care and education specialist. And today I actually do more in the realm of device training, and I do a lot of translational writing for both consumers and healthcare professionals.
Dr Carol Wysham:
Yes, and I'm an endocrinologist. I take care of primarily patients with type 1 and type 2 diabetes and have been increasingly interested in how we manage, screen, and take care of our patients with diabetes and understand all of their comorbidities. So this is a very important topic for my personal interest.
What we're going to be reviewing today are just discussions from both Gene and Hope on how they screen and help manage some of these comorbidities we've talked about. But importantly, we are going to really emphasize some of the revisions to the most recent ADA Standards of Care as they relate to some of the goals and treatments. So I hope that we can emphasize and familiarize the audience with these new goals.
So Gene, starting with you, can you recommend how primary care providers might screen for some of these comorbidities?
Dr Eugene E. Wright:
Absolutely. What I've learned and what I do is now that when I see one condition, I start to look for the others. So when we see diabetes, we need to look for chronic kidney disease and cardiovascular disease, especially congestive heart failure in the presence of chronic kidney disease. And now we know that patients with diabetes and/or obesity are at risk for metabolic-associated fatty liver disease.
Dr Carol Wysham:
Thank you. And what about your consideration of the four pillars of care for helping to decrease complications of diabetes?
Dr Eugene E. Wright:
Well, this is an area that is evolving as well. We've often thought about just the old ABCs, if you will, of care and management of patients with diabetes with the A1c blood pressure and cholesterol or lipids. Now we've added a fourth pillar to that, and these are agents of cardiovascular and kidney benefit on top of a foundation of lifestyle modification and diabetes education. And it's very important that we talk about the foundation of lifestyle modification and diabetes education.
Dr Carol Wysham:
The most recent standards of care in the recommendations for hyperglycemia have elevated obesity as a potential target and goal for therapy. Can you speak to the underlying reason for that?
Dr Eugene E. Wright:
Certainly. The management of obesity is a goal because obesity is associated, with and without diabetes, with many of these excess risks for cardiovascular disease, dyslipidemia, chronic kidney disease, and metabolic-associated fatty liver disease, all of these risks are increased in the presence of diabetes. Therefore, the management of obesity with diabetes is a primary goal.
Dr Carol Wysham:
Great. Thank you. And Hope, Gene talked about the importance of the foundation of lifestyle management and diabetes education upon which these other choices are made. Would you please review your view of what is important in lifestyle management and the kind of education that is needed in our patients with diabetes?
Hope Warshaw:
Certainly. I think we have really evolved over the years with what was formerly called medical nutrition therapy for diabetes. There is a lot more meeting people where they are, getting a sense of what they're eating, where are they accessing food, and what changes are they willing to make. So helping people make those small changes. And we also need to talk, because I don't think people get nearly enough conversation, about physical activity. And I would say dieticians and other certified diabetes care and education specialists are fully competent at covering that topic area.
Again, what goals are you able and willing to set with your exercise? I mean, we know, actually, the ADA Standards of Care talk about four types of activity, aerobic and decreasing sedentary activity, which could be a really good place to start with someone, doing some resistance training. So there are multiple types of activity. I think we can make that fairly simple.
One point I want to make that I think is very relevant to this four-pillar piece that we're talking about here that ADA published, I think for the first time in 2022, is really the two categories of pharmacological agents that have become available over the last few years of the SGLT2 inhibitors and then our GLP-1 and GLP-1 combo meds. They're allowing conversations that we never were able to have before to talk about, how can we help you lower your risk of chronic kidney disease? How can we help you lower your weight? How can we help you with maybe minimizing NAFLD? I haven't quite gotten the new language.
But I mean, really, to me, the obesity conversation today, which let's face it, what? 80%+ of people with pre-diabetes and type 2 diabetes have overweight or obesity. But there's a valuable conversation that we can have and amazing medications. So we need to break down that construct of it's lifestyle. And if you don't succeed with lifestyle, then perhaps enter medication and then perhaps enter the concept of metabolic surgery. I think those conversations are intermingling, and I think dieticians and other CDSs can have that conversation, as well as endocrinologists and primary care providers.
Dr Carol Wysham:
Actually, that leads quite well into my next question. In the ADA Standards of Care, they have what they've termed the decision cycle for type 2 diabetes. Can you summarize what that means in clinical practice?
Hope Warshaw:
Is that to me?
Dr Carol Wysham:
Yes. I'm sorry, Hope.
Hope Warshaw:
Yep, I have that page opened in the ADA Standards of Care. At the center of that decision cycle, which is specific to type 2 diabetes management, they talk about two goals of care, one being prevention of complications, and the other is interestingly optimized quality of life. And I think that is where the dialogue between the provider and the person with diabetes is so central because each person defines their quality of life and what quality of life means to them. I think we have often heard as clinicians, "Well, one thing I want to be able to do is get on the floor and play with my grandchildren." I mean, that seems to be a common theme. For some people, it might be taking fewer medications. So those are the two goals of care in this decision cycle.
Dr Carol Wysham:
That's very good. And it is obviously a complicated conversation, but involves discussion with the patient, making a mutual decision and then evaluating the outcomes from that, and then returning to the beginning, having the conversation so that it is an ongoing cycle of care, as we know. My favorite saying is that we're talking about a marathon, not a sprint, and that we're taking care of patients over decades, hopefully. And we need to be prepared for ongoing discussions about how medications or lifestyle fits into patients' own lives.
Gene, let's talk about the pharmacologic therapies for cardiorenal protection.
Dr Eugene E. Wright:
This is another interesting area because we know that the association between diabetes and cardiovascular disease, for instance, is great. It has been suggested in the past that diabetes may be a cardiovascular disease manifested by dysglycemia. The same could be said for chronic kidney disease. So this speaks to the interconnectedness of the cardiorenal and metabolic systems. So when we start thinking about reducing risks for cardiorenal disease progression or cardiorenal protection, we should choose therapies that will benefit, not just lowering glucose, but these other conditions. So, in the case that we've talked about earlier with chronic kidney disease, we have very good evidence that the SGLT2 inhibitors have a very profound effect on reducing the risk for chronic kidney disease progression. Similar to atherosclerotic cardiovascular disease. We can see significant improvement in the reduction of the risk with the GLP-1 receptor agonists. So we need to pick and choose wisely, particularly looking to prevent or significantly delay the onset of complications.
Dr Carol Wysham:
That's great. Thank you.
Hope, there are, in the newest standards of care, new goals for the management of hypertension. Can you review those?
Hope Warshaw:
Sure. I think the goal this year in 2023 was to harmonize the hypertension goal or cut point, if you will, to define hypertension between some of the other cardiology organizations, and it is 130/80.
Dr Carol Wysham:
Yes, I think that's correct. And that's an important message. It's gone back and forth. It used to be less than 130/80. We didn't feel like we had the data. So I was actually the Chair of the Practice Committee and the ADA when we changed it back to less than 140/90. And indeed, over time, there's been more and more studies to support that less than 130/80. So yes, thank you, Hope.
And Gene, how about the new targets to reduce LDL? These are the ones that I think most people are struggling with. So can you review those?
Dr Eugene E. Wright:
So what I'll do, Carol, I'm going to hit three highlights of that. I think the first one is that the guidelines would recommend in people with diabetes ages 40 to 75 without atherosclerotic cardiovascular disease, or ASCVD, a moderate-intensity statin in addition to lifestyle. The second point I'd like to make in people with diabetes ages 40 to 75 with atherosclerotic cardiovascular disease risk factors, a high-intensity statin in addition to lifestyle. The goal for this would be to reduce the LDL by 50% from baseline and to a target LDL goal of less than 70 milligrams per deciliter. Now, the third one would be in people with diabetes and established atherosclerotic cardiovascular disease, a high-intensity statin treatment with a goal to reduce the LDL by 50% with a target of less than 55 milligrams per deciliter. And if this is not achieved with a statin alone, you might think about adding another agent such as ezetimibe or PCKS9 inhibitor.
Dr Carol Wysham:
Yeah, thank you. And there are newer agents, like bempedoic acid, that are available as well if patients are unable to tolerate the other medications.
All right. Well, thank you both for this very interesting conversation. I'd like to ask you both if you have any take-home messages you'd like to provide for the audience. I'll start with Hope.
Hope Warshaw:
As we're talking, I'm just sitting here reflecting. I think sometimes we have to start by asking a person with diabetes who's sitting in front of us, what do they know about diabetes and what do they know about how diabetes is managed. Because I think the three of us have been around diabetes for a long time and the concepts that a person may have... I mean, we can't expect them to have been updated on all of these many changes, but I think there are some really good news messages that we can give people today about management, about jumping on good, tight glycemic management early and avoiding complications. And even the message of really for that person with type 2 diabetes, the cardiovascular disease message is a key message. And yet I think what people hear in the outside world still is you're at risk of losing your eyesight and you're at risk of being on renal dialysis. And so just making sure that people understand current general concepts of diabetes care.
Dr Carol Wysham:
Thank you. And Gene?
Dr Eugene E. Wright:
My take-home point would be diabetes is a multi-morbid condition that requires, one, early risk assessment, two, aggressive treatment, and three, ongoing multidisciplinary management for the best results.
Dr Carol Wysham:
Yes, it truly does take a village. Well, thank you again both for the very interesting conversation today, and thank the audience for tuning into today's video.